Recognition of Medical Direction and Support of Poison Center Activities

It is the position of the American College of Medical Toxicology that medical direction of poison centers be provided by at least a full-time equivalent (1.0 FTE) board-certified medical toxicologist. In order for this commitment to be filled, poison centers must provide direct salary support for these positions in proportion to the physician time commitment.

Poison Centers serve as an important component of the health care system and the American College of Medical Toxicology supports their role. A necessary and essential element to the functioning of poison centers is the provision of medical direction by qualified physician medical toxicologists. Medical toxiocologists who provide medical direction or who provide professional on-call coverage for poison centers are encouraged to do so as a component of their medical practice and thus are entitled to appropriate compensation for their professional services.

Medical Directors of regional poison information centers are physician toxicologists responsible for providing medical direction and supervision of these centers. As providers of medical diagnostic and treatment consultative services, physicians, in concert with a staff of expert Doctors of Pharmacy, pharmacists, nurses, educators, and other health care professionals, provide the medical oversight of these centers. However, the Medical Director must assume final responsibility for the clinical activities of the staff. Other responsibilities of the Medical Director include the establishment and periodic review of triage and treatment protocols; quality assurance; education of staff, health professionals and students; daily case reviews; and other operation activities. In addition, the Medical Director or designee must be available at all times to provide consultation to the center staff and to other health care professionals seeking advice from the center on medical toxicology issues. This responsibility can only be fulfilled by a physician qualified in medical toxicology, and these physicians should be routinely consulted for all critical poisonings. Poison Center Medical Directors must be board certified in medical toxicology, either by the American Board of Medical Toxicology, the Subboard of Medical Toxicology of the American Board of Medical Specialties, or the American Osteopathic Board of Emergency Medicine’s Certification of Added Qualifications in Medical Toxicology. Physicians designated on-call for consultations to the poison center must also be similarly board-certified or board-prepared as defined by meeting qualifications for sitting for the examination and accepted by the Board in writing. Toxicology fellows-in-training may provide on-call consultations with appropriate back-up of board-certified or board-prepared medical toxicologists. The scope of responsibilities for Medical Directors is so extensive for operational activities, oversight, and direction, plus the requirement of continuous on-call, that the total time commitment per center must be at least one physician FTE (1.0 FTE). The on-call commitment alone requires more than a single physician. However, there must be an on-site Medical Director who devotes a minimum of one-half FTE solely to operational activities, exclusive of on-call time. The remaining one-half FTE could be filled by additional Medical Director time and/or other qualified physicians. In order for this commitment to be filled, poison centers must provide direct salary support for these positions in proportion to the physician time commitment.

One of the stated indications for federal funding under the Poison Center Stabilization and Enhancement Act from the United States Department of Health and Human Services (USDHHS) is to support “medical direction” of poison centers. Consistent with the need for committed oversight and medical direction by medical toxicologists, the American Association of Poison Control Centers (AAPCC) identified the provision of medical direction at a sufficient level of effort to ensure appropriate medical oversight as a criterion for designation as a certified center. This has been codified as a minimum of 0.5 FTE plus 0.25 FTE for every 25,000 poison center calls. The availability of medical direction is certainly germane to guideline development and support of recommendations made in complex medical cases.

The Institute of Medicine in its 2004 report “Forging a Poison Prevention and Control System” noted that the median supported time of medical direction to poison centers at the time of a survey in 2000, was only 0.5 FTE. The USDHHS recently reported that, between 2000 and 2002, median supported time for medical direction grew slightly to 0.76 FTE. They also noted that many poison centers “count unpaid medical toxicologist backup…as volunteers.” “All centers use consultants as back-up medical toxicologists and other medical experts, and these are often not paid.” The provision of medical “back up” as an unpaid volunteer activity is inconsistent with the required commitment and responsibilities of physicians supplying these services.

Despite the fundamental importance of physician participation in the proper functioning of poison control centers and some improvements in the funding for medical directors, it is still true that many medical toxicologists who provide toxicology medical direction, do so on a voluntary basis. A recent survey (Offerman SR, Brent J, Wax PM. Medical toxicologist attitudes on compensation for services provided to poison control centers J Med Toxicol 2010;6:79-80) conducted by members of the American College of Medical Toxicology indicated that only 49% of responding toxicologists reported being fully compensated for their poison center work while 28% were never compensated. Only 40% of surveyed toxicologists who were poison center directors felt that they were fairly compensated for their work. This is despite all respondents (100%) feeling that toxicologists provide a useful service and 97% who feel that toxicologists should be compensated for their work.

The American College of Medical Toxicology’s mission is to “…advance quality care of poisoned patients and public health through physicians who specialize in consultative, emergency, environmental, forensic, and occupational toxicology.” Physicians who provide medical direction to specialists in poison information at the nation’s poison control centers should undertake this activity as a component of the practice of medical toxicology, and strive to improve the development of a system of poison prevention and information. Doing so on an unpaid and volunteer basis is inconsistent with this paradigm.

ACMT encourages individual poison centers and their funding agencies to recognize the quality medical oversight and expertise provided by their medical directors and medical toxicology consultants by providing financial support consistent with the time and effort expended.